Alcoholism Treatment and Total Health Care Utilization and Costs

T study by Holder and Blose attempted to answer an impor­ tant health policy question: Can alcoholism treatment, as op­ posed to treating alcohol­related medical complications—because it is actually provided to a large population motivated to seek care— result in reduced overall health care costs? Few studies had been done to examine how alcoholism treatment affected overall health care utilization and costs, and as more insurance compa­ nies and health maintenance organi­ zations (HMO’s) began covering or providing alcoholism treatment, this became an important question. The results of Holder and Blose’s study provided significant evidence that al­ c o h o l i s m t r e a t m e n t r e a l l y w a s cost­effective for health care plans. Holder and Blose’s study was the first to examine alcoholism treat­ ment and health care costs in a large (approximately 1,700 persons) con­ tinuously enrolled treated population over a long (4 year) time period, which gave the researchers time to study the population for several months both be­ fore and after treatment. The popula­ t ion w a s geogr aphi c al ly diver se, coming from all 50 States, and multi­ ple cost­and­utilization measures were used to determine treatment effec­ tiveness. The size of the sample per­ m i t t e d a n a l y s i s o n a l c o h o l i c s o f different ages, and the longer time period made possible a more detailed view of alcoholics’ health care pre­ treatment cost patterns. Holder and Blose’s study also was the first to show the econo m ic adva n t a g e o f making treatment available in the early stages of alcoholism and thus provided a rationale for identifica­ tion and intervention programs to motivate alcoholics to be treated at a younger age and earlier in the course of their disease. Previous studies, using data from HMO’s or prepaid plans and fee­for­ service systems, that also had indicat­ ed reduced health care costs as a result of providing alcoholism treatment had been plagued by methodological problems, such as small numbers of cases in specific geographic areas. These problems had severely limited their generalizability and thus their usefulness for health policy. Holder and Blose’s study looked at health care utilization and costs for enrollees under the Federal Employees Health Benefits Program with Aetna insurance company. Alcoholics were de­ fined as any person receiving treatment under the primary diag­ nosis of alcoholism. Claims filed by 1,697 treated alcoholics and their family members continuously enrolled during the study pe­ riod were examined together with a sample of 3,598 randomly selected, similarly aged, enrolled families with no family mem­ bers receiving alcoholism treatment. The 4­year average per capita monthly pretreatment health care costs for a family with an alcoholic member was almost 100 percent ($209.60 compared with $106.50) above that for a family with no members receiving alcoholism treatment for the same period. (Much of this cost came from inpatient alcoholism treatment; however, even with­ out these treatment expenses, the average per capita monthly

T his study by Holder and Blose attempted to answer an impor tant health policy question: Can alcoholism treatment, as op posed to treating alcoholrelated medical complications-because it is actually provided to a large population motivated to seek careresult in reduced overall health care costs? Few studies had been done to examine how alcoholism treatment affected overall health care utilization and costs, and as more insurance compa nies and health maintenance organi zations (HMO's) began covering or providing alcoholism treatment, this became an important question. The results of Holder and Blose's study provided significant evidence that al c o h o l i s m t r e a t m e n t r e a l l y w a s costeffective for health care plans.
Holder and Blose's study was the first to examine alcoholism treat ment and health care costs in a large (approximately 1,700 persons) con tinuously enrolled treated population over a long (4 year) time period, which gave the researchers time to study the population for several months both be fore and after treatment. The popula t ion w a s geogr aphi c al ly diver se, coming from all 50 States, and multi ple costandutilization measures were used to determine treatment effec tiveness. The size of the sample per m i t t e d a n a l y s i s o n a l c o h o l i c s o f different ages, and the longer time period made possible a more detailed view of alcoholics' health care pre treatment cost patterns. Holder and Blose's study also was the first to show the econo m ic adva n t a g e o f making treatment available in the early stages of alcoholism and thus provided a rationale for identifica tion and intervention programs to motivate alcoholics to be treated at a younger age and earlier in the course of their disease.
Previous studies, using data from HMO's or prepaid plans and feefor service systems, that also had indicat ed reduced health care costs as a result of providing alcoholism treatment had been plagued by methodological problems, such as small numbers of cases in specific geographic areas. These problems had severely limited their generalizability and thus their usefulness for health policy. Holder and Blose's study looked at health care utilization and costs for enrollees under the Federal Employees Health Benefits Program with Aetna insurance company. Alcoholics were de fined as any person receiving treatment under the primary diag nosis of alcoholism. Claims filed by 1,697 treated alcoholics and their family members continuously enrolled during the study pe riod were examined together with a sample of 3,598 randomly selected, similarly aged, enrolled families with no family mem bers receiving alcoholism treatment. The 4year average per capita monthly pretreatment health care costs for a family with an alcoholic member was almost 100 percent ($209.60 compared with $106.50) above that for a family with no members receiving alcoholism treatment for the same period. (Much of this cost came from inpatient alcoholism treatment; however, even with out these treatment expenses, the average per capita monthly health care costs for families with alcoholic members were still higher: $180.88).
The average monthly health care costs for alcoholics gradual ly increased over the 36 months prior to treatment, rising dramat ically in the last 6 months. Holder and Blose interpreted this to mean that the average alcoholic's emotional and physical prob lems appeared to increase in the 6 months before he or she de cided to enter treatment. After alcoholism treatment, costs for the alcoholic population declined and continued to do so for the next few years. This pattern was almost identical for men and women.
For those alcoholics who were 44 years of age and under at the time of treatment, posttreatment health care costs eventually fell to those seen 36 months prior to treatment. For those 65 years of age and over, the posttreatment decline in costs was not so dramatic, and health care costs remained above pretreatment levels. Holder and Blose suggested that costs in this older popu lation could be attributed to increasing medical care costs caused by aging as well as to the existence of alcoholrelated health problems resulting from a longer period of abuse.
Subsequent studies, many also by Holder and Blose, have confirmed and extended these original findings. For example, Holder and colleagues (1992) reviewed a 20year period of re search into the potential total health care cost savings associated with alcoholism treatment, further confirming that untreated al coholics use health care resources at twice the rate of their popu lation control group and that this difference can be eliminated if they undergo alcoholism treatment. This study supported the re sults of the original Holder and Blose study showing that younger drinkers, if treated for their alcoholism, will have lower health care costs than older nontreated alcoholics.
Although Holder and Blose's study was not designed to com pare treatments, treatment costs, and lengths of stay, their find ing that overall treatment for alcoholism reduced subsequent health care costs encouraged further research examining the ef fectiveness and costeffectiveness of various types of treatment.
For example, Holder and colleagues (1991) found that overall, the most effective treatment modalities were not the most expen sive. This finding should further stimulate researchers to conduct clinical studies in which both cost and effectiveness are measured.
It is now clear that the future of alcoholism treatment depends on extending costeffectiveness studies beyond those of generic "alcoholics" to identifying different types of alcohol problems (e.g., alcohol abuse, alcohol dependence) and beyond generic "treatment" to more specific treatment techniques or settings (e.g., inpatient, intensive outpatient). Once these distinctions are made, studies can be done on the most costeffective type of treatment for each type of alcohol problem. Holder and Blose's landmark study demonstrated elegantly and definitively the cost benefits of any type of alcoholism treatment. They also proved that research in the alcoholism treatment field could yield results t h a t w e r e a s e x a c t a s t h a t o f r e s e a r c h i n o t h e r b r a n c h e s of medicine. ■ Treatment and Training Center, St. Lukes-Roosevelt Hospital Center, New York, New York.